ACCIDENT/INJURY/INCIDENT REPORT FORM
NOTE – This form does not take the place of Workers Compensation First Report of Injury Form or any other
accident report required by the College’s Insurance
EMPLID #: ___________________________________________ Date of Incident: ______________________
Person Involved: ______________________________________ Time of Incident: ______________________
Address: _________________________________________ City, ST, Zip: ______________________________
Phone: ________________________________ Email: ______________________________________________
☐ Student ☐ Faculty/Staff ☐ Visitor/Guest Division or Department: _________________________
Location - be specific (Bldg., Hall, Room, Parking Lot, etc.): __________________________________________
1. Description of Accident (Include Instructor, Course, EMPLID, if supervised activity, Complaints, etc.) Use
additional sheets as necessary.
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2. Description of action taken including any first aid administered (Corrective Actions, Times, Findings, etc.)
Use additional sheets as necessary.
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Assistance administered by: _______________________________________ Phone: _____________________
Witness Name: ___________________________ Phone: __________ Email: ___________________________
Witness Name: ___________________________ Phone: __________ Email: ___________________________
Person Involved in Accident: __________________________________ __________________
Signature Date
Instructions:
Complete PDF form online, print and sign. If completing paper copy, please use pen and print clearly.
Submit form to Human Resources, Safety Officer, and/or Chemical Hygiene Officer as appropriate
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Office Use
Public Safety Director/Chief of Police: __________________________________ __________________
Signature Date
Director of Finance & Facilities: __________________________________ __________________
Signature Date
